March 23, 2006

Larry Brilliant's InSTEDD: Can the Internet help stop pandemics?

(Updated March 2008, see below.)

I had never heard of GPHIN until Larry Brilliant made it a key part of his "wish speech" (video) at the TED conference in February, where he received the TEDprize and was therefore entitled to express a "wish" asking the attendees (a very high-powered and tech-oriented crowd) to help him realize it. Here is what Larry wished for:

To build a powerful new early warning system to protect our world from some of its worst nightmares.

(Read: from deadly pandemics).

The system should be transparent, with basic information freely available to everyone, preferably in their own language, and will be housed in a neutral country, independent of any single government, any single company, any single UN agency, but will offer its alerts, data, access to all.

Brilliant (picture left) pointed to an existing Canadian system, GPHIN, as the nucleus that could form the basis for what he dubbed INSTEDD, for International System for Total Early Disease Detection (of course, the TED in the word is a hat-tip to the prize).

GPHIN, he said, "detected SARS and other epidemics and disasters in time to help the world respond and contain them". Quite a statement – Brilliant added that the system is now being applied to avian flu. GPHIN stands for Global Public Health Intelligence Network. It is a web-based system, now in its second version, that continually scans thousands of online information sources (media, local newspapers – often the first source – wires, public statements, health bulletins, blogs) in seven languages (English, French, Spanish, Arabic, simplifiied and traditional Chinese, and Russian) looking for news of infectious diseases outbreaks, other pathogens, natural disasters, and more.

GPHIN was established by Health Canada's Lab Centre for Disease Control, in cooperation with several other entities. Basically, it is a sophisticated Internet search engine, based on technology developed by a Canadian firm, designed to crawl the network, filter the information for relevancy and patterns, detect early signs of a potential problem and flag them. The flagged data is then sent to public health experts to be analyzed, including officials at the World Health Organization, at food inspection agencies, and others, who are responsible for verifying the threats and confirming or deny the outbreak (the public right now does not have access to the information, in order to avoid rumors or panic).

Being based on data and information that resides on the Internet, the system may look unreliable (if an information is not online, GPHIN won't capture it). But an increasing quantity and quality of information is becoming available on the web, including that originating in the most remote corners of the world. And consider the alternative: reports of outbreaks phoned in or faxed in by local public health officials, who may have only a partial view of what's going on, can be subject to political pressure to suppress the information (to avoid scaring away tourists or businessmen, for example) or may delay reporting because they're overworked.

This last point – speed – is crucial, and is at the core of Larry Brilliant's approach (and of the Internet's contribution). Brilliant is a man of many lives. He co-founded the Seva Foundation, which helped cure blindness in millions of people in Asia and promote public health elsewhere. He played a key role, while working at the World Health Organization, in eradicating smallpox in India. He took part in the birth of "The Well", probably the most iconic virtual community. He started several tech companies. He hung around the Grateful Dead. And more. And one month ago was named as the head of the Google Foundation, the philantrophic arm of the company that everybody knows.

A quite extraordinary biography that he summarizes as follows: "I'm the luckiest guy in the world: I got to see the last case of smallpox in the world, and recently in India I may have seen the last cases of polio".

In the 1960s nobody thought that smallpox could be eliminated, but twenty years later it was practically gone. How did it get eradicated? "Mass vaccination was not sufficient", Brilliant said at TED, "early detection and early response are key". At the conference he told of his experience in India: thousands of people were dispatched from village to village, knocking on every door showing pictures of kids with smallpox and trying to identify cases – and isolate them immediately, what Brilliant calls "create a circle of immunity" around them. That's what worked then – casting the wider possible net to gather information early, and react immediately – and that's what may work again, with the help of technology, against the "nightmare diseases" of tomorrow: SARS, avian flu, and other possible global pandemics.

Consider the most actual scare, bird flu, a lethal strain of which (H5N1) has spread around the world in the last two years sparking fears of a pandemic (the microscope image on the right, from the National Geographic, shows the virus - appearing in gold – growing in cells, which are pictured green).

According to data from the WHO (updated 21 march 06), 184 people have contracted the virus, of which 103 have died, 42 in Vietnam alone (see the BBC's map of outbreaks). Cross-infection from birds or other animals (cats in Germany and dogs in Central Asia have also reportedly been affected) to humans is very rare. It has only happened where people have been in very close contact with infected birds. And the virus has not yet jumped from human to human.

But "if the disease mutates to human-to-human transmission, the world as we know it will stop, there will be no airplanes flying", said Briliant. He did a private survey of epidemiologists: 15% said that they thought there would be a pandemic of bird flu within three years; 90% that it would happen in the next two generations, making one billion people sick.

There are no vaccines for bird flu yet. And global mobility makes the spread of diseases easier. So the only response goes back to the village-to-village smallpox strategy: early detection and early response. The key with these diseases, he told the San Francisco Chronicle, is "you find them early and kill them before they spread".

That's where GPHIN and INSTEDD come in. An article in ITWorldCanada published early last year gives a few examples of GPHIN at work. Excerpts:

GPHIN monitors infectious diseases – not just in humans, but in animals and plants – and also tracks chemical incidents, radioactive exposures, dangerous products and natural disasters.

“Essentially we monitor everything from bugs to bombs. But always from the standpoint of how it impacts public health.” GPHIN, Mawudeku said, can track classical outbreak metrics – such as the number of infected people and resulting deaths – as well as the magnitude of the threat. During the 2003 SARS outbreak, she said, information was retrieved not just from affected countries but from regions across Asia. “That helped us determine the event’s geographic distribution.”

The system also tracks “remedial” measures adopted by countries or by public carriers, such as airlines, to protect travelers. More than 40 per cent of WHO information on potential public health risks comes from GPHIN – information which, when tested with member countries, usually proves accurate.

According to Mawudeku, GPHIN retrieved the first suggestive report on SARS in November 2002. It was an article in Chinese on how an unusual number of otherwise healthy people were visiting hospital emergency rooms with acute respiratory illness symptoms. That information was disseminated to public health authorities. A month later, she said, another article in Chinese was identified on how a large number of people in China’s Guangdong province were falling ill.

She said it was only in January 2003 that the first English article was retrieved. “Even that didn’t mention an outbreak, but was about the increase in anti-viral drug sales by a pharmaceutical company. From that we deduced something unusual was going on.”

The system was further developed into GPHIN2, after which Brilliant would now like to model the "total early disease detection" system he envisioned at TED. The idea is to turbocharge GPHIN2 by expanding the search and analysis capabilities, the number of news sources tracked and the languages covered. Satellite data could be mashed up with the GPHIN data to help confirm reports rapidly; and so on.

The system could also be used to detect early signs of famine, environmental degradation, water poisoning, toxic spills, bioterror, exposure to nuclear agents, and basic information should be available to anyone. "The goal is to have the earliest possible warning of all bad things (…) and contain them with early response", he told Wired.

That's quite a challenge. Technological – Brilliant's new closeness with Google will be helpful for that, and many other companies and people have indicated support – as well as political and social, for INSTEDD will create unprecedented transparency in the very sensitive field of public health, and may end up enlisting many people as both audience and source of the information.

Brilliant is aware of it: he closed his speech in Monterey by describing the system as "a moral force for the world".

A group of TEDsters is now working with Brilliant on this, so there will be updates and more posts on this coming (by now you probably figured that I am quite enthusiastic about this project). Comments/suggestions?

Post 9/11, a Pittsburgh University public health expert called Ronald E. LaPorte proposed an “Internet Civil Defence Against Bioterrorism”. He described an “an ever alert, flexible electronic-matrix of civil defense” which could help government, NGOs, business and the public collaborate more effectively. He argued that Neighbourhood Watch schemes reduced crime by 25–75% and combining social monitoring with the Net might similarly lower bioterrorism risks. “…we can have 20 million educated, committed, and interconnected volunteers worldwide on the outlook for the prodrome of bioterrorism….In addition, with its operational effectiveness this network will increase the resilience of our social fabric, building a sense of belonging and identity.”

I wonder if there are some ideas to learn from this proposal. For instance, could GPHIN be missing a “high touch” human approach in its predominately “high tech” monitoring (although they do of course also use humans to analyse software results)? Remember the shock realisation of US intelligence post 9/11 that they didn't in fact have any meaningful on-the-ground intelligence, it was all hi-tech electronic whisperings that didn’t help them really understand what was going on.

So could GPHIN use a network of human listening posts, co-ordinated by electronic comms, on the ground in key regions and listening out for physical rather than digital whispers/gossip/stories/patterns/trends, etc. All of which gets added into the GPHIN database to be analysed by their software. (You can get quite sophisticated semantic analysis software these days to spot patterns within free text speech taken from depth interviews for instance). Just wondering if sometimes that would catch stuff the other system would miss, or catch it sooner. Unless of course there's such confidence that GPHIN electronic monitoring can spot everything that needs to be spotted.

I also wonder if there should be some kind of incentive in place for the public to actively keep a lookout for and report information. For instance, would people be encouraged to send in suspicious signs that could lead to a disease being spotted early if every legitimate posting was automatically entered into a draw for a monthly cash prize.

Perhaps the danger of too much low-quality clutter outweighs this approach, but the right incentive to galvanise people into being an active part of the alert system makes sense to me.

Then there’s the opposite approach (not at all mutually exclusive though) where reverse text billing can help with ongoing funding. So texting a number to alert anysuspicious signs of outbreak costs 50p, or whatever, and that revenue gets split between GPHIN and mobile operator. (With the right incentive people happily pay money to participate in a chance of winning, e.g. the lottery).

Finally, I definitely think that mobiles are the key to any consumer-based input device. What if people could just text, say, ALERT to a number, then perhaps get into an auto text response mini multiple choice question and answer session to determine the typology of disease warning, etc. (Their mobile’s geographic location should automatically be part of the information).

Andy's point about adding a "human intelligence" (humint) layer to GPHIN's "techint" (intelligence gathered using technical means) is an interesting one. For most people humint is synomymous with spies and clandestine activities, and it may actually be that some of the GPHIN information-gathering may have to happen in some covert way (think of the way the Chinese government tried to keep SARS "secret" for some time). But here it would be about finding a way - through a balanced use of incentives - to expand the number of sources, so that the outbreaks-monitoring net can be expanded and the overall speed of the process increased, without creating too much clutter. More comments?

UPDATE 27 March 06 - An interesting story on the front page of today's Herald Tribune about eradicating the "Guinea worm" plague in Nigeria has many echoes of Larry Brilliant's tale of why it is so hard to eradicate diseases and how superstition makes it harder: "A rare and stubborn pestilence":

Whatever secrets the turgid brown depths of the Sacred Pond of Ogi (Nigeria) may keep, there is one they betray quite easily: Why it is so infuriatingly hard to wipe even one disease off the face of the earth. (...) For untold generations here, meter- long, spaghetti-thin worms erupted from the legs or feet - or even eye sockets - of victims. (...) The searing pain drove them to plunge the blisters into the nearest pool of water, whereupon the worm would squirt out a milky cloud of larvae, starting the cycle anew. (...) Thanks to a relentless, 20-year campaign led by former President Jimmy Carter, Guinea worm is poised to become the first disease since smallpox to be pushed into oblivion. Fewer than 12,000 cases were found last year, down from three million in 1986. (...) It ought to be almost ridiculously easy to wipe out. (...) Wells can be drilled to prevent the afflicted from plunging their limbs into the village's drinking water. Or local water sources can be treated with a mild pesticide. (...) In 2001, Jacob Ogebe, a field officer for the Carter Center Guinea Worm Eradication Program, was trying to track down every pond in the area surrounding Ogi. He treated each with Abate, a mild pesticide that left the water potable, but killed the microscopic fleas that carry Guinea worm. But slowly, he realized that Ogi's villagers were misleading him. He heard rumors of a sacred pond, but no one would take him to it. (...) The villagers say they believe that the souls of their ancestors also dwell in it (...). After Ogebe found the pond, he said, villagers tried to dissuade him from treating it. "Some of them offered me money to hide it," he said. "But I told my boss at the Carter Center. Then each time I went to the village, people followed me around. There were threats on our lives." (...) "They refused the Abate," he said, adding with a grin: "But someone killed a dog and threw it in their sacred pond. People stopped drinking the water - and Guinea worm cases went down."

GPHIN is somewhat automated and somewhat rules-based, but still relies on human intervention for all necessary response. A truly resilient system would go further, connecting more network nodes -- such as hospitals, public health agencies and pharmaceutical companies -- and anticipating and automating responses based on a range of contingencies. Nevertheless, it's encouraging to see so much effort -- and so much leading-edge thought -- focused on networked IT systems and their potential to meet critical public needs. This is the seed of resilience. Progress depends on -- and is driven by -- collaboration. The greater the number of contributors, and the greater their insight and ambition, the faster we will make progress toward a truly resilient response.

UPDATE 19 April 06 - Here is something Larry Brilliant wrote a few weeks before TED2006 describing his vision for what he later called INSTEDD, for International Networked System for Total Early Disease Detection (this text was sent a few days ago by TED curator Chris Anderson to a few thousand people in the TED mailing list). I'm reproducing it here because it's a powerful vision, and because it offers a few more details that are not in the texts above:

I've been in conversations with WHO, CDC, Johns Hopkins and the other universities from the Pandefense "consortium" about using the prize - and the TED community - to build a virtual earth, with

multiple webcrawlers

infobots

comparative historical databases

hi-res coordinated satellite photography

IM and text messaging

several other IP based systems

...

for the earliest possible detection of new outbreaks of bird flu, novel diseases like SARS and ebola, as well as new emerging biological threats, whether bio-terror or bio-error - and extending to famine, flood, natural disasters, chemical and industrial spills, forced migration and other catastrophes where time is of the essence in responding.The world would not today be playing catch up with new pandemics if we had such a system in place 30 years ago; governments would not be able to hide cases of bird flu or genocide, they would not be able to delay reporting cases of polio and the world would have an entirely different view of emerging new communicable diseases if such a system were operative.I don't know if you know that SARS was first discovered by a group in Canada following up on reports from a webcrawler about cases of fever, even though the first cases were in China. The system they used, GPHIN (Global Public Health Intelligence Network) is a courageous Canadian government-owned system which crawls newspapers, websites, and public documents in only half a dozen languages. I would like to use the resources of the TED community to produce a "GPHIN on steroids" that would crawl 150 languages, be fully open source, transparent, and a trusted system, openly available to anyone especially at country and local level in the concerned countries, and at universities...

Latest news, Google, the Omidyar Foundation and VC firm Kleiner Perkins have pledged support, and many individuals around the world have done the same (there is room for more).

When Larry and his team at Google.org talked to the disaster
community about his wish, they told him simply: In a disaster, "We've
got to be able to find each other." Their needs broadened his vision.
Now, along with early detection, his system will offer disaster-relief
agencies a way to communicate and share data, to provide coordinated
early response to disasters.

The system is called INSTEDD (International Networked System for Total Early Disease Detection).

In
March 2007, the new system undergoes its first pilot project, Working
with the Rockefeller Foundation and NTI (Nuclear Threat Initiative),
six countries along the Mekong River (Vietnam, Thailand, Cambodia,
Laos, Myanmar and the Hunan region of China) will do a tabletop
exercise about how they would react to a pandemic flu.

INSTEDD's
goal is to become a trusted source of comprehensive disaster tracking
and response tools that enable users to operate more effectively in
times of crisis; and, more than that, to foster a community of
individuals, nonprofits, companies and government agencies involved in
the detection of, and response to, public threats.

(...) Says Mark Smolinski, Threat Detective at Google.org: "We don't even
have standards on how we collect basic information on human
demographics or health info during a disaster. That's something that an
organization like INSTEDD could help promote."

It has been almost exactly one year since I began my work at Google.org.
We've been in a bit of a quiet period during that time, meeting with
foundation leaders, activists, NGOs, and scientists -- and Googlers --
from all over the world. My major task has been to build a world-class
team, comprised of experienced Google managers paired with content
experts from the fields of climate change, global public health and
economic development to spearhead strategic initiatives for our
philanthropic efforts. There were four of us one year ago; today we are 25 people. (...) So where are we going now? Google.org is looking to better understand
the inextricable linkages among climate change, global public health
and economic development, and the impact of global warming on the poor.
We want to fund projects that are making a difference and that are
effective on a large scale.We live in very complicated times.
Global health, poverty, and climate are inextricably interrelated, and
it is the poor of the world who bear the heaviest burden. Google.org is
focused on learning initiatives that simultaneously fund good
organizations working in these areas and provide insights into "big
ideas" that could be scalable from these pilot projects.

Kleinberg was becoming an
expert on local disaster-preparation efforts. During her term as Palo
Alto's mayor, preparing a city emergency response plan was a priority.
At her urging, Palo Alto took the lead in Santa Clara County. She
helped launch Joint Venture's response initiative and she has been
involved in statewide discussions.So when INSTEDD Director
Peter Carpenter was looking for someone to get the start-up started, he
thought Kleinberg would be a natural. But she wasn't so sure. (...) Tuesday, she was at the United Nations with other
INSTEDD folks, enlisting U.N. agencies in their efforts.The company has $2.5 million from Google.org this year to get off the
ground. The staff members, some of whom work pro bono, are dispersed
around the world. Kleinberg keeps the virtual operation running from
her one-woman office.One of her first priorities is to change the company's name, a tortured
acronym designed to refer to the TED prize. "I'm sure we can come up
with something better," she said.

UPDATE Jan 2008 - InSTEDD launches its new website and logo and blogs. The meaning of the acronym has changed from Larry Brilliant's initial "International System for Total Early Disease Detection" to "Innovative Support to Emergencies Diseases and Disasters" -- which headlines a broader mission:

InSTEDD is an innovation labfor technologies designed to improve early disease detection and rapid disaster response.Disease
and disaster are usually viewed as separate topics, handled by
different agencies and specialists. But there is no humanitarian crisis
that does not have a health component, or a serious outbreak of disease
that does not have a humanitarian dimension.According to a recent Oxfam report, there has been a four-fold increase in the annual number of natural disasters.Increased
trade and travel, high-volume livestock and poultry operations, a
shifting climate and a burgeoning human population have also led to a
disturbing global increase and spread of newly identified pathogens (HIV/AIDS, SARS, hantavirus), a resurgence of familiar plagues (TB, malaria, polio), and the emergence of deadly new strains (H5N1 avian influenza, West Nile virus, antibiotic-resistant staphylococcus).Mortality
statistics only begin to tell the story. The costs of a disease
outbreak or a natural disaster are devastating for families,
communities and countries. AIDS leaves children orphans. Floods, fires
and earthquakes destroy homes. Disease outbreaks cripple food supplies
and ruin livelihoods.InSTEDD works with universities,
corporations, international health organizations, humanitarian NGOs and
communities. Together, we work to identify or craft and then field-test
technologies for better data collection and analysis, more efficient
communications, and more effective response. InSTEDD will, for example,
be adapting new social networking capabilities for humanitarian
coordination, and testing inflatable satellite dishes able to be
carried in a backpack.InSTEDD’s mission is to discover, develop,
test, deploy and share information about technologies that buy critical
time. Through better disease detection and response times, outbreaks
can be contained and possibly prevented. Through better disaster
response, more lives can be saved. Through collaboration better answers
can be found.

The InSTEDD technology field lab page, with descriptions of some of the tools they're testing, is here.

“WHAT does a moral person do, given all the problems and suffering in the world? How do you focus?” ... Dr Brilliant and his 40-strong team have at last agreed a strategy for Google.org ... unveiled on January 17th ...

Google.org had compiled a list of over 1,000 ideas. These were
reduced to 11, focused on the world's “biggest, most imminent, least
well resourced problems”. Each of the 11 was allocated to a different
member of the Google.org team, who acted as its advocate in a process
of further scrutiny and selection that Dr Brilliant likens to being in
court. This led to the five initiatives announced this week. In these
deliberations, the focus was on what Google specifically had to offer
in each area, given its technological and engineering capabilities,
mastery of information, entrepreneurial culture and global reach.

In broad terms, the outcome is not terribly surprising. Google.org
will pursue five “core initiatives” in three areas: fighting climate
change (a particular obsession of Messrs Brin and Page); economic
development (a passion of Sheryl Sandberg, the unseen driving force
behind the creation of Google.org); and building an early-warning
system for pandemics and other disasters—something Dr Brilliant wished
for when he won the 2006 TED Prize, which first brought him to Google's attention.

Accordingly, Google.org has made a $5m grant to InSTEDD,
a non-governmental organisation that is building a rapid-reporting
platform to connect people on the ground with those monitoring
pandemics. It hopes to raise the quality of public services in poor
countries by improving the flow of information both to those who run
them and to those they serve. It has big ambitions to help small and
medium enterprises in developing countries. It is investing in the
development of a plug-in electric car. And it has launched a project
called RE<C to develop renewable energy that is cheaper than coal, “within years not decades”.

Comments

Hi – a couple of comments/thoughts:

Post 9/11, a Pittsburgh University public health expert called Ronald E. LaPorte proposed an “Internet Civil Defence Against Bioterrorism”. He described an “an ever alert, flexible electronic-matrix of civil defense” which could help government, NGOs, business and the public collaborate more effectively. He argued that Neighbourhood Watch schemes reduced crime by 25–75% and combining social monitoring with the Net might similarly lower bioterrorism risks. “…we can have 20 million educated, committed, and interconnected volunteers worldwide on the outlook for the prodrome of bioterrorism….In addition, with its operational effectiveness this network will increase the resilience of our social fabric, building a sense of belonging and identity.”

I wonder if there are some ideas to learn from this proposal. For instance, could GPHINN be missing a “high touch” human approach in its predominately “high tech” monitoring (although they do of course also use humans to analyse software results)? Remember the shock realisation of US intelligence post 9/11 that they didn't in fact have any meaningful on-the-ground intelligence, it was all hi-tech electronic whisperings that didn’t help them really understand what was going on.

So could GPHINN use a network of human listening posts, co-ordinated by electronic comms, on the ground in key regions and listening out for physical rather than digital whispers/gossip/stories/patterns/trends, etc. All of which gets added into the GPHIN database to be analysed by their software. (You can get quite sophisticated semantic analysis software these days to spot patterns within free text speech taken from depth interviews for instance). Just wondering if sometimes that would catch stuff the other system would miss, or catch it sooner. Unless of course there's such confidence that GPHIN electronic monitoring can spot everything that needs to be spotted.

I also wonder if there should be some kind of incentive in place for the public to actively keep a lookout for and report information. For instance, would people be encouraged to send in suspicious signs that could lead to a disease being spotted early if every legitimate posting was automatically entered into a draw for a monthly cash prize.

Perhaps the danger of too much low-quality clutter outweighs this approach, but the right incentive to galvanise people into being an active part of the alert system makes sense to me.

Then there’s the opposite approach (not at all mutually exclusive though) where reverse text billing can help with ongoing funding. So texting a number to alert any
suspicious signs of outbreak costs 50p, or whatever, and that revenue gets split between GPHINN and mobile operator. (With the right incentive people happily pay money to participate in a chance of winning, e.g. the lottery).

Finally, I definitely think that mobiles are the key to any consumer-based input device. What if people could just text, say, ALERT to a number, then perhaps get into an auto text response mini multiple choice question and answer session to determine the typology of disease warning, etc. (Their mobile’s geographic location should automatically be part of the information).

In regards to your post. Another Canadian company is using the backbone of a system like GPHIN to deliver real time alerting to the global public. www.avianalert.com provides alerts by email and SMS. I think your idea of input to the alert system by SMS would be a great addition. Perhaps the Avian Alert founders can work with their technology partners to add this technology.

The problem with the avian alert system is that it uses a static geographic location. For example, a user can submit a request to be alerted if a human outbreak occurs in Hessen, Germany. However, if the person is travelling in Spain and an outbreak occurs in that region, they will not be alerted, even though they have their mobile phone with them.